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Assistive Technology: Outcomes and Efficiency.

N.B. You can read this report as full text, below, or as a PDF using the icon at the bottom of the page.

1. Introduction

Assistive Technology is one of the key areas the Government is investigating as it takes forward its thinking about the NHS and social care. We published a Special Report on this topic in June of last year. That introductory report looked at some of our general attitudes to the increasing use of technology in everyday life, and at the emotional reactions that can affect our willingness to accept it when it becomes a care necessity - rather than an active personal choice.

The report also provided a brief description of current and developing technology types - with an annex highlighting a selection of recent resources; and went on to discuss some of the key policies and on-going research affecting the use of assistive technology; and the wider challenges that confront its further positive development as a tool to improve care, support and independence.

This special report takes the issue into much more practice-focussed territory and discusses the evidence - and the challenges - emerging from a series of evaluations that have attempted to identify, and quantify, the results of real, local investment in telecare services.

Written by Mike Beazley and Kim Conner*, the report includes debate on the outcomes impact of telecare and its possible contribution to efficiency savings. The report concludes with practice recommendations, based on the programme of evaluations that Mike and Kim believe can help to improve the quality of life for people who use services and their carers, and which may also help them, and funding organisations, achieve better value for money.

2. Background

The term, Assistive Technology (AT), is used in this article to describe both telecare and telehealth services. An excellent plain English description of telecare and telehealth is produced by Counsel and Care in association with Tunstall Ltd, and can be found on Careknowledge here.

Telecare is a major part of today's assistive technology and among the most promising developments in personalised care for the future. It can be effective in improving safety and making independent living more sustainable. As council charges for personal care at home continue to rise above inflation, it is also increasingly cost effective for people who use services and for their carers. For councils too, it has potential to achieve significant efficiencies. The careful choice of equipment and the right balance with other services are both critical in supporting better outcomes and in keeping costs reasonable.

This article looks at the results of a series of evaluations carried out over 2 years using a method designed to demonstrate the service outcomes and costs associated with telecare use.

It is not known accurately how many people currently use telecare and telehealth in England. The most recent estimate in 2010, suggested that about 1.7m people had one or more items of telecare equipment, (perhaps as many as 300,000 of these are simple personal alarms or smoke alarms linked to a call centre): with perhaps 5000 using telehealth equipment of different kinds.

3. How do Telehealth and Telecare make a difference?

3.1 Telehealth

The main evidence on telehealth effectiveness in the UK is flowing from the Dept of Health's sponsored research in three "Whole System Demonstrator Sites" where randomised control trials have been taking place since 2008. The early headline findings published by the Department of Health are:

"…if used correctly telehealth can deliver a 15% reduction in A&E visits, a 20% reduction in emergency admissions, a 14% reduction in elective admissions, a 14% reduction in bed days and an 8% reduction in tariff costs. More strikingly, they also demonstrate a 45% reduction in mortality rates."

The mortality improvements are the most remarkable, and bring long-awaited evidence to commissioners and clinicians. The Government says that three million people with Long Term Conditions (diabetes, congestive heart failure, chronic obstructive pulmonary disease) and/or social care needs could benefit from using telehealth and telecare. The headlines emphasise the potential to avoid hospitalisation wherever possible.

3.2 Telecare

The evidence for telecare is less firmly established in formal research but the results of our own work since 2009 with teams in 50 council areas across England suggests that telecare is also effective, especially with older people, and in particular in:

improving safety at home and supporting independent living

delaying or avoiding admissions to care homes

reducing the escalation of care needs at home (e.g. stepping up the level of home care support )

reducing the number of emergency admissions to hospital

reducing the number of days spent in hospital

4. Why evaluate telecare?

Typically, little routine information about the performance, outcomes or costs of telecare or telehealth is available, locally, or nationally. In general, local commissioning teams are interested in questions such as:

Are we getting telecare to the right people?

How effective is it in sustaining independent living?

Is it cost-effective when compared with alternative services?

Is it worth investing in an expansion of the service?

How can we monitor the performance of the service?

Across the 50+ council areas we visited in 2009-2011, none had any significant telecare performance measures in their normal performance reports in spite of significant financial investment. There are no national indicators in this field, and local arrangements still tend to mirror national reporting requirements, in spite of their different purposes.

5. Evaluating service outcomes and costs

The method we have used in our work with local authorities, takes a representative sample of service users who were using the telecare service on a specific past date - normally about one year previously - so that outcomes can be demonstrated. Detailed service histories are collated and costed. Case reviews build a picture of key events and services over the evaluation period. Crucially, the review determines what would have been the most likely alternative service outcome if telecare had not been available: and how much would that alternative have cost?

The evaluation report shows what is currently being achieved, but also indicates the potential for further changes to service outcomes. It can be used to help model the financial impact of telecare expansion over several years.

5.1 Evaluation Results

In this article we look briefly at the results of an evaluation carried out across a single English region in 2011, with a sample of 642 people living in 8 local authority areas.

5.2 How telecare helps to sustain independent living and who can benefit

The results showed that telecare was effective in all areas, but to varying degrees:

in prolonging independent living, by reducing the escalation of care service needs, most often when used as part of a wider support package. Numerically, the greatest beneficiaries were older people, particularly those who had dementia or who were frail and at risk from falls.

in reducing avoidable admissions to hospitals and supporting safe discharge home

in deferring or avoiding admissions to care homes

Table 1 shows how telecare helped to avoid the escalation of particular services. The key points of interest include the extent to which high cost services such as hospital admissions, care homes and home care services were avoided. This suggests positive outcomes for people who use services and carers.

Table1: Service Escalation Deferred or Avoided

Number

Percentage

Continuing Health Care

1

0.3

Day Care

7

2.4

Home Care

61

20.5

NHS provision

125

42.1

Nursing

10

3.4

Personal Assistant

2

0.7

Reablement

2

0.7

Residential

86

29.0

Respite

29

9.8

Sitting Service

2

0.7

Sleeping night

3

1.0

Supported Living

1

0.3

The most frequently occurring instances of service escalation deferred or avoided were hospital episodes - usually due to:

the prevention of, or faster response to, falls amongst older people

avoided or delayed admissions to residential care (especially for people with dementia), and reductions in home care provision

the reduced use of reablement services, as a result of the reduction in hospital episodes

5.3 Who gets telecare and why

Table 2 shows the 'primary client categories' of people using telecare. A significant proportion of people - 38% of the sample - were allocated telecare for 'reassurance'. This may be desirable as an early step towards prevention, but is not necessarily an effective use of overall resources where those for people who have complex, intensive or unstable health are under severe pressure. Less than half of the people in the sample were allocated telecare in response to specific 'eligible' needs, such as dementia or severe disability.

Table 2: primary client group of telecare users

Number

Percentage

All Telecare Users

642

Reassurance

244

38.0

Prevention

101

15.7

Other Telecare Users

297

46.3

of which:

Dementia

37

5.8

Frailty

89

13.9

Learning Disability

11

1.7

Mental Health

20

3.1

Physical Disability

131

20.4

Sensory Impairment

9

1.4

5.4 Efficiency savings

The evaluation showed variable efficiency savings. Where telecare was provided for 'prevention' or 'reassurance' purposes, telecare added extra cost, but where it was used to meet a more defined need, it was shown to produce efficiency savings, and these were substantial in some cases.

For the 642 people included in the evaluation, annual savings were achieved of between £449,512 and £499,458 for social care and from £137,224 to £152,471 for the NHS.

Table 4 shows the values of costs deferred or avoided (i.e. average per head, averaged across all councils) over a single year. The efficiencies are given in a range, to allow for the fact that the method is designed to produce results for management use, not for research purposes.

Note: The higher rate estimate results directly from the calculated comparisons of expenditure saved where telecare was used as a substitute service and 'avoided' other services. The lower estimate is offered as a conservative figure that can be used safely for financial planning, to reflect the degree of judgement involved in the calculations.

Table 3: Efficiency Savings Estimates

Average Annual Saving

Sample size

Social Care

NHS

Lower estimate

Higher estimate

Lower estimate

Higher estimate

All Telecare Users

642

£700

£778

£214

£237

Reassurance

244

-£220

-£200

£0

£0

Prevention

101

-£132

-£120

£0

£0

Other Telecare Users

297

£1,689

£1,877

£463

£515

-Dementia

37

£2,337

£2,627

£467

£519

-Frailty

89

£628

£709

£532

£591

-Learning Disability

11

£20,860

£23,194

£491

£546

-Mental Health

20

£1,700

£1,941

£424

£472

-Physical Disability

131

£1,614

£1,794

£535

£594

-Sensory Impairment

9

£572

£708

£151

£237

Some key points to note are:

The high social care efficiency savings were from costs avoided for people with learning disability and people with dementia, (but note the relatively small samples, suggesting the need to investigate in more detail)

In many cases, telecare was very cost effective where it substituted for high cost care home placements, and where it reduced night staffing, safely, in group home settings or independent accommodation.

The more frequently found savings from people with dementia: especially in deferring or avoiding care home admissions

The costs associated with prevention and reassurance (but note that the long term preventative value of telecare use for these people cannot be easily assessed)

6. Conclusions

The results of this study in one region, are similar to the wider experience across English council areas, and have helped to support a number of conclusions. These are set out below with practice recommendations that we believe can help to improve the quality of life for people who use services and their carers, and can also help them and funding organisations to achieve better value for money.

NB: In order to make best use of HTML format, the paragraphs below are set out in narrative form. In the PDF, for the report, the conclusions are set out in tabular form, which works better in that form of presentation.

6.1 Where Telecare forms part of a carefully planned package of support, it is effective in helping to prolong independent living and increasing safety. To take account of this conclusion, commissioning organisations need to:

Make sure that care managers and reviewers properly understand telecare's potential and limitations, and can get expert advice

Strengthen skills and knowledge through quality training at induction, ongoing and PQ levels

Check that business processes and guidance include telecare, so that it is a consistent part of integrated support planning for independent living

People who use services and their carers should be advised to

Take action early to get a skilled and independent assessment and insist that telecare and /or telehealth options are considered

Ask for advice, even if they don't qualify for financial support. This can be helpful in making independent arrangements

Remember that carers may be entitled to an assessment of their own needs - and telecare may be very helpful

6.2 Older people are likely to be the most numerous telecare users to benefit, followed by younger adults with physical or learning disabilities. We found few users from mental health services, and this is a potential area for cost effective growth. To take account of this conclusion, commissioning organisations need to:

Allocate telecare use on a consciously targeted basis, according to local population needs and gaps in support and include particular consideration of people with dementia and people with learning disabilities

People who use services and their carers should be advised to:

Make sure that - whatever their particular needs - assistive technology is considered as a serious option in meeting some or all of them. It may be less intrusive and costly than the alternatives, and there may well be benefits for carers

6.3 Telecare can be effective in getting people back on their feet after illness or accident, or a stay in hospital, especially where it can be provided quickly, and by skilled advisers. For example, it may substitute effectively for one or more home care visits within a multi-visit daily care plan. To take account of this conclusion, commissioning organisations need to:

Check that reablement/ intermediate care teams are aware and knowledgeable and ensure that rapid installation is available - on a same day basis if possible

People who use services and their carers should be advised to:

ask if telecare options are available to get help quickly or stay in touch with carers if they need help - particularly if they want to get home from hospital quickly but are unsure about being on their own

6.4 Telecare can be good value for money for people who use services, and help councils achieve efficiency gains. To take account of this conclusion, commissioning organisations need to:

Establish benchmarks to review costs and efficiency on a periodic basis.

People who use services and their carers should be advised to:

Check the costs of telecare and ask a care manager about the value of this, compared to the alternatives - particularly If they are eligible for financial support and are using a direct payment

6.5 The commissioning of telecare is not always clearly targeted and is even supplier-led in some areas. Where Telecare has been used without clear purposes - for "reassurance" (usually as an add-on) - it cannot be demonstrated as an effective use of resources. To take account of this conclusion, commissioning organisations need to:

Re-visit commissioning strategies to ensure that telecare is included as a component and is a consciously targeted, and costed element

6.6 It is not easy to demonstrate evidence that telecare is effective in prevention: but this does not mean its use should be discontinued. More often, prevention needs to improve, and telecare has an important role to play in reducing isolation and containing costs. To take account of this conclusion, commissioning organisations need to:

Review prevention strategies to include marketing of telecare to self-funding individuals

People who use services and their carers should be advised to:

Ask for an assessment or advice from the council on telecare options, if they are worried about getting help in an emergency - this might help bring peace of mind

6.7 Telecare is not widely embedded in most council's mainstream care systems - there are separate rules and processes for access, eligibility, charging, assessment, and review. This can be wasteful and counter-productive. To take account of this conclusion, commissioning organisations need to:

Check that business processes for assessment, support planning and review and associated guidance all include telecare

6.8 Telecare is effective in reducing avoidable use of health services, especially unplanned hospital admissions and (to a lesser extent) delayed discharges. However, only one PCT in our programme was currently investing in this service. To take account of this conclusion, commissioning organisations need to:

Recognise that "Rapid response telecare" - i.e. same day installation, is helpful in reablement and in enabling prompt discharge from hospital.

Mike has more than forty years experience in social care, as a care worker, manager, educator, inspector and consultant in England and Scotland. With a management background in the County of Avon, he joined the Social Services Inspectorate, and managed the team that set up the social care performance assessment system in England from 2000. He transferred to the CSCI in 2004 and left to set up an independent consultancy, Care Performance Partners, in 2006.

Since then, his work has included projects with DH (CSED), with CQC, with ADASS, (regionally and nationally) and with numerous councils with social care responsibilities. The focus of most of this work has been on performance and quality, management, and improvement strategies.

Kim Conner

Kim is a founding partner of CaPP, and has over 15 years of experience in performance management across health and social care. In her former career with the Department of Health, she worked on NHS performance management systems and reports. Joining the Social Services Inspectorate in 1998, she was a key designer and manager of the national information and evidence system, PADI, and also developed systems for the Inspectorate's Victoria Climbié Audit.

After joining CaPP, she worked with the DH CSED team to develop a methodology and toolkit for evaluating and planning efficiency improvements through Telecare. She has led on analytical methods and publications for CSCI / CQC, developed quality analysis tools for ADASS and worked on transformation strategies with local councils.